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---------------- <br /> UNIFIED <br /> --------------UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION(one form per facility) <br /> TYPE OF ACTION 0 1.NEW PERMIT 5.CHANGE OF INFORMATION [1 7.PERMANENT FACILITY CLOSURE <br /> a00. <br /> TRANSFER PERMIT <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> FACILITY INFORMATION <br /> FACILITY <br /> ID <br /> �(AgeenLcy�Uw 0,#nd�y) � <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 3. <br /> BUSINESS NAME(Same as FACILITY NAME DBA-Doing Business As) <br /> r or <br /> National Petroleum-Stockton 103. CITY 104. <br /> BUSINESS SITE ADDRESS Stock-ton <br /> 713 N.El Dorado St. 405. <br /> IE 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or <br /> ❑FACILITY T 3.FARM [1 4.PROCESSOR [1 6.OTHER Trust lands? ❑Yes No <br /> H PROPERTY OWNER INFORMATION <br /> 407, P HONE 409. <br /> PROPERTY OWNER NAME <br /> New Era Energy,LLC. (408) 577-0202 409. <br /> MAILING ADDRESS <br /> 405-11 Camille Circle 410. STATE 411. zlP CODE -412. <br /> CITY <br /> San Jose CA 95134 <br /> III TANK OPERATOR INFORMATION <br /> 428-2 <br /> TANK <br /> K OPERATOR NAME 428-1. PHONE <br /> Engineer's Associates,Inc. (510) 677-4467 428-3 <br /> MAILING ADDRESS <br /> 405 Camille Circle Suite 11428-4 STATE 478-5 ZIP CODE <br /> -428-6 <br /> CITY C <br /> San Jose A 95134 <br /> 1[V. TANK OWNER INFORMATION. <br /> 414. PHONE 415. <br /> TANK OWNER NAME (408) 577-0202 <br /> New Era Energy,LLC. -416 <br /> MAILING ADDRESS <br /> 40 0! <br /> 5_1 <br /> CITY I I Camille Circle 417. STATE 418. ZIP CODE 419. <br /> San Jose - CA 95134 [1 6.STATE AGENCY 420. <br /> OWNER TYPE: [1 4.LOCAL AGENCY/DISTRICT rl 5.COUNTY AGENCY <br /> n 7.FEDERAL AGENCY 0 8.NON-GOVERNMENT <br /> PHONE <br /> (408) S77-0�202 <br /> V..'BOARD OF EQUALIZATIONST STORAGE FEE ACCOUNT NUMBER <br /> HQ <br /> TY(TK) <br /> 421. <br /> 7 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VL PERMIT HOLDER INFORMATION <br /> Issue <br /> 423 <br /> [D 4.TANK OPERATOR <br /> Issue permit 7 8 3 t and send legal notifications and mailings to: 141.FACILITY OWNER <br /> 3.TANK OWNER 5,FACILITY OPERATOR 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.- APPLICANT'SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal reguirements. 425. <br /> F 4.. PHONE <br /> APPLICANT SIGNATURE DATE <br /> 3/20/2014 510)6774467 <br /> 427 <br /> T 426- APPLICANT TITLE <br /> APPLICANT NAME(print) <br /> NickP t I Manager. <br /> ick Patel <br /> UPCF UST-A Rev.(12/2007) <br />